Possible Solutions to Common Problems in Death Certification

National Center for Health Statistics, January 1997
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Introduction
A death certificate is a permanent record of an individual’s death. One purpose of the death certificate is to obtain a simple description of the sequence or process leading to death rather than a record describing all medical conditions present at death.

Causes of death on the death certificate represent a medical opinion that might vary among individual physicians. In signing the death certificate, the physician, medical examiner, or coroner certifies that, in his/her medical opinion, the individual died from the reported causes of death. The certifier’s opinion and confidence in that opinion are based upon his/her training, knowledge of medicine, available medical history, symptoms, diagnostic tests, and available autopsy results for the decedent. Even if extensive information is available to the certifier, causes of death may be difficult to determine, so the certifier may indicate uncertainty by qualifying the causes on the death certificate.

Cause-of-death data is important for surveillance, research, design of public health and medical interventions, and funding decisions for research and development. While the death certificate is a legal document used for legal, family, and insurance purposes, it may not be the only record used, because, in some cases, the death certificate may only be admissible as proof of death. The following provides suggestions, largely from Hanzlick (1994), for handling situations where cause of death is difficult to certify.

Uncertainty
Often several acceptable ways of writing a cause-of-death statement exist. Optimally, a certifier will be able to provide a simple description of the process leading to death that is etiologically clear and to be confident that this is the correct sequence of causes. However, realistically, description of the process is sometimes difficult because the certifier is not certain.

In this case, the certifier should think through the causes about which he/she is confident and what possible etiologies could have resulted in these conditions. The certifier should select the causes that are suspected to have been involved and use words such as "probable" or "presumed" to indicate that the description provided is not completely certain. If the initiating condition reported on the death certificate could have arisen from a pre-existing condition but the certifier cannot determine the etiology, he/she should state that the etiology is unknown, undetermined, or unspecified, so it is clear that the certifier did not have enough information to provide even a qualified etiology.

The Elderly
When preparing a cause-of-death statement for an elderly decedent, the causes should present a clear and distinct etiological sequence, if possible. Causes of death on the death certificate should not include terms such as senescence, old age, infirmity, and advanced age because they have little value for public health or medical research. Age is recorded elsewhere on the death certificate. When malnutrition is involved, the certifier should consider if other medical conditions could have led to malnutrition.

When a number of conditions or multiple organ/system failure resulted in death, the physician, medical examiner, or coroner should choose a single sequence to describe the process leading to death and list the other conditions in Part II of the certification section. "Multiple system failure" could be included as an "other significant condition" but also specify the systems involved. In other instances, conditions listed in Part II of the death certificate may include causes that resulted from the underlying cause but did not fit into the sequence resulting in death.

If the certifier cannot determine a descriptive sequence of causes of death despite carefully considering all information available and circumstances of death did not warrant investigation by the medical examiner or coroner, death may be reported as "unspecified natural causes." If any potentially lethal medical conditions are known but cannot be cited as part of the sequence leading to death, they should be listed as other significant conditions.

Infant Deaths
Maternal conditions may have initiated or affected the sequence that resulted in an infant death. These maternal conditions should be reported in the cause-of-death statement in addition to the infant causes.

When Sudden infant death syndrome (SIDS) is suspected, a complete investigation should be conducted, typically by a medical examiner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical history is reviewed, and a complete autopsy is performed, then the death can be reported as (SIDS). If the investigation is not complete, the death may be reported as presumed to be (SIDS).

Avoid Ambiguity
Most certifiers will find themselves, at some point, in the circumstance in which they are unable to provide a simple description of the process of death. In this situation, the certifier should try to provide a clear sequence, qualify the causes about which he/she is uncertain, and be able to explain the certification chosen.

When processes such as the following are reported, additional information about the etiology should be reported if possible: